Panretin Gel Prior Authorization Criteria - Medicare Part D

Prior Authorization Criteria for Approval

Panretin Gel will be approved when BOTH of the following are met:

1. ONE of the following:
   1. The patient has a diagnosis of cutaneous lesions associated with AIDS-related Kaposi’s sarcoma (KS)
      OR
   2. The patient has an indication that is supported in CMS approved compendia for the requested medication
      AND
2. ONE of the following:
   1. There is evidence of a claim that the patient has been treated with the requested medication within the past 180 days
      OR
   2. The prescriber states the patient has been treated with the requested medication
      OR
   3. ALL of the following:
      1. ONE of the following:
         1. BOTH of the following:
            1. The patient has a diagnosis of cutaneous lesions associated with AIDS-related Kaposi’s sarcoma (KS)
               AND
            2. The patient does NOT require systemic anti-Kaposi’s sarcoma therapy
               OR
         2. The patient has an indication that is supported in CMS approved compendia for the requested medication
            AND
      2. The prescriber is a specialist in the area of the patient’s diagnosis (e.g., oncologist, dermatologist, infectious disease) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
         AND
      3. The patient does NOT have any FDA labeled contraindications to the requested medication

Length of Approval: 12 months